1 - Hawaii Department of Health



|1. |Agency Referring to |

| |Name: |      |

| |Address: |      |Phone No.: |      |

| | |      | |      | |      |Fax No.: |

|2. |Service Referring to: |      |

|3. |Referring Agency |

| |Name: |      |

| |Address: |      |Phone No.: |      |

| | |      | |      |

|4. |Consumer Demographic Information |

| |Name: |      |AMHD Ref. No.: |      |

| |Gender: | Male |

| |Address: |      |Home Ph. No.: |      |

| |If homeless, |      | |      | |      |Cell Ph. No.: |

| |indicate where | | | | | | |

| |the consumer can | | | | | | |

| |be found | | | | | | |

|5. |Legal Guardian (if applicable) |

| |Name: |      |Relationship: |      |

| |Address: |      |Phone No.: |      |

| | |

| |Axis I: |      |

| |Axis II: |      |

| |Axis III: |      |

| |Axis IV: |      |

| |Axis V: |      |

|7. |Eligibility |

| |The consumer has been determined eligible for AMHD services: | Yes | No |

|8. |Forensics |

| |Legal Status: | Conditional Release | Other (specify): |      |

| |Include a copy of the current conditional release or other current orders, if applicable. |

| |Court Date (if applicable): |      | |

| |Forensic Coordinator Name: |      |Phone No.: |      |

| |Parole/Probation Officer Name: |      |Phone No.: |      |

|9. | Hospitalized Consumers (if applicable) |

| |Name of Hospital: |      |

| |Discharge Meeting Date: |      |Discharge Date: |      |

|10. |Health Insurance |

| |Name of Health Insurance Company: |      |Insurance Card No.: |      |

| |(i.e., HMSA, Kaiser, etc.) |

|11. |Income |

| |Monthly Income: |$ |      | |

| |Source of Income (i.e., work, SSI, SSDI, DHS, etc.): |      |

| |Other Assets (i.e., savings, etc): |      |

|12. |Psychiatrist |

| |Name: |      |

| |Address: |      |Phone No.: |      |

| | |

| |Name: |      |

| |Address: |      |Phone No.: |      |

| | |

| |Agency Name: |      | |

| |CM/ACT Team Name: |      |Phone No.: |      |

| |CM/ACT Team Address: |      |Fax No.: |      |

| | |

| |Is housing needed? | Yes | No |

| |Does the consumer have a Sec. 8 rental subsidy? | Yes | No |

| |If referring for housing, indicate what level: | 24 Hour Group Home |

| |check only one (1) level | 8-16 Hour Group Home |

| | Semi-Independent Group Home |

| | Support Housing |

| | Shelter Plus Care |

| |If referring for housing, does the consumer require an accessible home or reasonable accommodation? | Yes | No |

| |If yes, please describe what the consumer needs: |      |

| |      |

| |      |

|16. |Citizenship |

| |Citizenship Status: | US | Other (specify): |      | | Unknown |

|17. |To be completed for referrals to the Kalihi Palama Community Fitness Restoration Program (KFIT) |

| |a. |Current legal charges: |      |

| |b. |Legal Status (check the status that applies): | 704-404 |

| | | 704-406 |

| | | Other, specify: |      |

| |c. |Order to Treat: | Yes | No |

| |d. |Advance MH Directive: | Yes | No |

| |e. |History of Violence: | Yes | No |

| | |If yes, date of last/most recent physically aggressive, assaultive behavior: |      |

| | |If yes, date of last/most recent threatening behavior: |      |

| |f. |Risk of Suicide: |Previous suicide attempt: | Yes | No |

| | |If yes, date of last/most recent suicide attempt: |      |

| | |Suicidal ideation: | Yes | No |

| |g. |Elopement Risk: |Previous AWOL/AWA: | Yes | No |

| | |If yes, date of last/most recent episode of AWOL/AWA: |      |

| |h. |Current or previous participation in fitness classes: | Yes | No |

|18. |Interpreter Services |

| |Does the consumer need an interpreter? | Yes | No |

| |If yes, what language: |      | |

|19. |Rep Payee Services |

| |Does the consumer have a Rep Payee? | Yes | No |

| |If yes, name of Rep Payee: |      |Phone No.: |      |

|20. |Other Current Services |

| |Indicate any services the consumer is currently utilizing: | Peer Coach |

| | Respite |

| | CRF - amount owed: |$ |      |

| | CBI (includes 1:1 wrap) |

| | Clubhouse |

| | DVR |

|21. |Please include the following documents: |

| |Consent to release information |

| |Master Recovery Plan (current) |

| |Most recent psychiatric evaluation with multiaxial diagnosis which is signed and dated |

| |Medical Problem List (include proof of PPD) |

| |Conditional Release or other Current Court Order (if applicable) |

| |HCR 20 (if applicable) |

| |Homeless certification (if referring for housing and if applicable) |

| |Copy of the order naming the guardian. (if #5 applies) |

|Complete #22 only if you are referring to a service listed in a, b, c, d or e below. If the service you are referring to is not listed in #22, go to #23. |

|22. |Please include the documents for the following services, if available. |

| |Please note: This is in addition to the documents required in #21 |

| |a. Specialized Residential Treatment, Day Treatment, Intensive Outpatient Hospital, E-ARCH: |

| |Nursing Assessment (most recent) |

| |Psychosocial Assessment |

| |Risk Assessment |

| |LOCUS (most recent) |

| |Psychological Testing |

| |Substance Abuse Assessment |

| |Medication Sheet |

| |Medical History and Physical (completed within one year of referral date and includes Rubella Titer/proof of immunizations, PPD) |

| |Narrative update that includes presenting problem, precipitating events and justification for the service |

| |Special diet requirements |

| |Dental needs |

| |Required for referrals to Specialized Residential Treatment: What is the current discharge plan upon completion of the program. |

| |b. Hale Imua |

| |Nursing Assessment (most recent) |

| |Psychosocial Assessment |

| |Risk Assessment |

| |Psychological Testing |

| |Substance Abuse Assessment |

| |Medication Sheet |

| |Medical History and Physical (completed within one year of referral date and includes Rubella Titer/proof of immunizations, PPD) |

| |Special diet requirements |

| |Dental needs |

| |LOCUS (most recent) |

| |c. KFIT |

| |Current psychiatric routine medications (name, strength/dosage, route, schedule) |

| |Current PRN medications. Include information on when the last PRN dosage was given. |

| |Add any medications being taken for medical problems listed on the medical problem list in #21. |

| |LOCUS (most recent) |

| |d. ACT, CBCM, and Outpatient Treatment |

| |Nursing Assessment (most recent) |

| |Psychosocial Assessment |

| |Risk Assessment |

| |LOCUS (most recent) |

| |Psychological Testing |

| |Substance Abuse Assessment |

| |Medication Sheet |

| |Medical History and Physical (most current) |

| |Dental needs |

| |e. PSR |

| |Nursing Assessment (most recent) |

| |Psychosocial Assessment |

| |Risk Assessment |

| |LOCUS (most recent) |

| |Substance Abuse Assessment |

| |Medication Sheet |

| |Medical History and Physical (completed within one year of referral date and includes Rubella Titer/proof of immunizations, PPD) |

| |Narrative update that includes presenting problem, precipitating events and justification for the service |

|23. |Referral Form completed by: |      | |

| |Print Name | |

| | |Date: |      |

| |Signature | |

| |

|PROVIDER DECISION FORM |

| To: |      |From: |      |

| |Referring Agency | |Provider and Type of Service |

| Consumer Name: |      |

|  |      |  |      |

|DOB: | |AMHD Ref#: | |

|  |  |  |

|Date Referral Received: |      | |

|Date Decision Rendered: | Accepted | Denied |

|Service Referred to (POS Provider): |      |

|If consumer was denied for this service, please complete the rest of this form |

|Current Diagnosis: |Axis I: |      |

| |Axis II: |      |

| |Axis III: |      |

|Reason for Denial of Referral: |

|  Consumer refused service |

|  Does not meet criteria for this service (Please provide explanation): |

|Insufficient documentation, please provide the following information: |

|  |      |

| |      |

| |      |

| |      |

| Consumer may be accepted in the future under the following circumstances: |

|  |      |

| |      |

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| |      |

|It is recommended that this consumer pursue alternative placement/treatment with another provider or at another level such as: |

|  |      |

| |      |

|Medical/Clinical Director Review: |      |  |

|  |Print Name |Date: |      |

|  |Signature |  |

|Administrative Executive Review: |      | |

|  |Print Name |Date: |      |

|  |Signature | |

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